The advent of affordable computer information systems, and improvements in software and technology, has lead to many improvements and gains in business and society over the last 30 years. Those entities that were created as a result of these technology advances have probably gained the most from it, as they were developed and grew up within the new technology framework. However, many other entities existed prior to the advent of these new technologies and have had to redefine their business needs and processes in order to adapt these new technologies into their existing business. This has created many improvements, but has also created many new problems and constraints as well.
The health care industry is a prime example of a pre-computer industry, although not the only industry, that has worked diligently to add new technology into existing business structures and processing methods in order to gain improvements and efficiencies. For explanation purposes, the health care industry, and more specifically the dialysis clinics, will be used as an example of this technology transition in order to aid comprehension of the background of this invention. The use of this example is not meant to limit the scope of the background or of the invention to the health care field or to dialysis clinics, but rather to aid in the understanding of the invention.
For the most part, the health care industry is an information based business that focuses on two primary activities. One activity is the care and assistance of patient's health care needs and the other is the generation of profits. In order to properly care for and treat a patient, a lot of information is required to be promptly available for review by the health care team. This information can be broken down into two main categories. The first category of information is more static in nature. This includes data like the patient's name, address, telephone number, insurance carrier, place of employment and so on. This is information about a patient that usually does not change often or with great frequency. The other category of information is more dynamic. This category includes such things as the patient's past and current medical history, current symptoms, laboratory test results, current medications, the nurse's review prior to the attending physicians visit, the prescribed treatment and a host of other variable data.
In the pre-computer era, all of the patient's static and dynamic information and data was manually created, recorded and filed in a chart, usually designated by the patient's name. This data and information file has two primary functions. The first function is to enable the attending physician to review data and assists in properly diagnosis and prescribing treatment for the patient. The chart also assists the nurses in administering the treatment correctly by aiding in communicating the physician's orders. In short, one primary function of the chart is for communication among the health care team. The second function is as a medical/legal record. This record allows for the proof of delivery when billing for the medical services and supplies provided. It also provides a legal record in case of a law suit. With this record, a health care entity can prove in court what they did, when they did it and who did it.
A patient's chart is considered the primary source for all of the information necessary to treat the patient and to provide for the business issues of billing and maintaining legal documentation. A patient's chart contain tabbed separators that include such sections as demographics and insurance information, doctor's notes and progress, vascular access, medication records, lab results, problem lists, dietary notes, and a host of other possible categorizations. In this manner, the treating health care professionals are able to access the information about a patient that they require by going to the tabbed section of the patient's chart and reviewing the information contained therein. However, health care has become more specialized and a greater variety of information has become available. This has resulted in more sources of information and more possible categorizations. The advent of the computer and its ability to efficiently track and report out information has exacerbated this situation as the reporting of information from each source has become more detailed and comprehensive. Currently, a patient's chart is not the only source of information on a patient, nor is it even a complete medical record. If a patient's consulting physician has prescribed other medications or treatments, that information may not be included in the primary physician's patient chart. Similarly, if the patient has visited a different source of care, such as a hospital or another physician's office, that information and the results from the visit may be lacking as well. By the same token, a hospital's or consulting physician's patient records may lack information present in the primary physician's patient chart. As a result, these multiple patient charts may have redundancies as well as missing information between the charts. This has resulted in a breakdown of the communication function of the chart, and its primary function has become that of an event log to prove what a specific health care team has done for billing and legal reasons.
A dialysis clinic is a specialized outpatient clinic and for the reasons above a patient's dialysis chart is not the only record of the patient's information. Typically, in order to be more productive, reduce costs, and to assure the proper care of the patient, health care teams will create information, work practices, and systems that enable them to do their jobs more effectively. For example, nurses often create a summary sheet, or listing, for all of their patient's medications that are to be given during the dialysis treatment. They usually create another sheet that allows them to record the patients' names and all of the patient's medication requirements. Then, when the patients all arrive in a short span of time for dialysis, they can simply go to their summary sheet, flip through the list by patient name, and copy down the medications that are needed for that patient's dialysis. This saves them the time that would be required to pull out each patient's chart, flip to the medication section, write down the necessary information, replace the chart and then continue for the rest of the patients currently being treated. They then go to the medication cabinet and retrieve the required medication for their patients at one time. While at the medication cabinet, they record on another sheet the same information pertaining to which patient is getting what medication. The nurses also record on the treatment record the name of the medication and the time the medication was administered to the patient. The treatment record is used for many purposes, including for billing. From this treatment sheet, often another summary sheet of administered medications is created for billing purposes, for restocking the medication cabinet, for verifying the current inventory and for cross checking to ensure that the amount of medication administered equals the amount of inventory that decreased during the day.
Another example of multiple or alternative databases that exists is exemplified by the use of the current dialysis machines. These machines have indicators or viewing screens on them. These screens or indicators show such information as the patient's pulse, their blood pressure, the blood and dialyate flow rate and other relevant information. This equipment can also store and present these information measures during the course of dialysis for trend line analysis based upon the time interval that the nurse or physician sets the dialysis machine to record that information. However, once that patient has completed dialysis and the machine is set up for the next patient, all of the information is lost or erased, unless it is captured in an electronic or manual format. In a manual information dialysis clinic, the nurses would generally record these measures on a treatment sheet during dialysis. They may then go to the patient's chart and re-record some of that same information in the summary sheets, such as blood pressure trends and weight gains/losses. Even if the dialysis machine information is captured in an electronic format, the usual result is to print off the information so that the printed treatment record can be inserted into the chart, and the nurses still record blood pressure trends and weight information into a summary sheet.
In short, there are many other “work-around” subsystems that the physicians, nurses, technicians and clerks have developed in order to cope with inadequate information systems and tremendous quantities of paperwork while trying to treat the patient and maintain profitability. Manual information systems are functional, and prevalent, even though they are no longer the most efficient means of capturing the data and presenting it in a user friendly way, given the advent of computer systems along with the current database technology and software. As a result, there has been a growing trend in the health care industry, amongst others, to create and utilize some form of an electronic Information Management System (IMS) to replace the manually created files. There are many IMS applications in the health care industry today, with varied levels of acceptance and success. These systems generally have a centralized database for all of a patient's information. The current methods and approaches to creating the centralized database is based primarily on having an accurate and reliable medical/legal record for billing and legal concerns along with the patient's medical information, rather than on improving and streamlining work flows and communication among health care workers.
In a dialysis clinic, like the majority of all businesses, there are a variety of workers, all at different skill levels and pay levels. There will be an attending Physician at maybe $200.00 per hour, an Administrator at $70.00 per hour, Registered Nurses at $45.00 per hour, Technicians at $25.00 per hour and a clerk or receptionist at $10.00 or $12.00 per hour. In the dialysis clinic, one of the primary roles of the nurses, technicians and receptionists is to provide the physician with the information they need, accurately, and in the way the physician needs it for diagnostic and treatment purposes. Similarly, the nurses need essential information to properly provide patient care. In a manual information dialysis clinic, the physician, the administrator, the nurses, the technicians and the clerks would gather all of the information appropriate to their level of responsibility and skill. In order to provide effective patient care while still trying to be cost efficient and productive, each clinic will have developed and assigned the data collection and recordation process and systems in a manner that they believe will be most effective and efficient. In general, the clinics try to have the data collection and recordation done at the lowest possible cost level while still assuring accuracy and completeness of information. These data collection and recordation systems vary from clinic to clinic based upon the resources and perceived needs of the clinic and the clinic's employees.
When a physician visits the patients, they review the information in the patient's chart, evaluate the patient, write down the appropriate changes/prescriptions deemed necessary to improve the patient's treatment on an order sheet in the chart and then continue on to the next patient. All of the changes are then recorded into various areas in the patient's chart as well as the multiple other summary sheets scattered across the dialysis clinic. This maximizes the use of the physician's time to visit and treat patients. However, sometimes errors are made in the transcription of the information into various places. These errors are a potential risk for serious problems. Additionally, it is inefficient to manually write the same information in multiple paper formats.
As computers became more readily available and useful in industry and business, more efforts began to develop a useful and functional electronic IMS in order to improve productivity, lower costs and reduce errors. To better understand the process and method of creating and using an electronic IMS, it is helpful to continue with our use of the dialysis clinic as an example. In the new technology environment (i.e. computers), many improvements were made over the manual method of collecting and formatting information. For example, today, the dialysis machines have electrical connection ports through which data can either be passed directly to a printer and/or send to a centralized data collection and compilation computer. If the information from the dialysis machine is printed off, it is a simple matter to place it in the patient's chart without having to transcribe it. Although these methods offer some advantages in reducing the data collection costs and in assuring the accuracy of some of the recorded data, they still present problems in their inability to become fully integrated with the multiple systems of information management utilized within a given clinic. As another example, Physicians can now carry a hand held computer from which they can enter prescriptions and have them immediately faxed or emailed to a pharmacy, while at the same time, the prescription and dosages gets captured in the centralized database for record keeping purposes. This is an effective and accurate means for collecting patient data and having it stored centrally. However, this method requires a significant upfront capital investment and it does not necessarily allow for the integration of the information into the multiple systems of information management.
For all of the advantages of the existing IMS structures, there are still many drawbacks to the current IMS technology structures. To begin with, the development of most IMS structures has been concerned with capturing all of the information electronically and storing it in a centralized location. The focus has been on assuring accurate information and on creating a comprehensive medical and treatment record for billing and legal reasons. While some of the information is easily captured in an electronic format, such as the monitored measurements from the dialysis machine, not all of the information is as easily gathered. For example, the nurse's preliminary examination of the patient's current status is still manually gathered. To accurately put this information into an electronic format, the attending nurse often first writes the information down on paper. He or she must then log in to a computer, travel through menus to find the right patient's chart, travel to submenus to find the correct section or form, enter the data and then log out of the system. Due to the rapid pace of patient care in the dialysis clinic, many times the nurses' first capture their notes manually and then enter their notes at the end of the shift/day. This is obviously time consuming, redundant and lowers productivity and reduces the cost effectiveness.
As another example, in the primarily manual scenario, as the attending physician goes about their rounds visiting patient, they do not need to interact with a computer. After their review of a patient's record and an examination, the attending physician may have some additional comments, notes and/or new prescriptions that need to be placed in the patient's file. Typically, the physician would simply jot this information down in the patient's chart and/or write up a prescription. The physician would then move on to see the next patient while a clerk or technician would record this information into various other forms and paper or electronic databases. With the current IMS protocols and in order to assure accuracy for the medical/legal record, the physician is required to log in to a computer, navigate through menus to find the patients file and the proper form, enter the additional data into the computer and then log off the data entry computer. Given that this data entry used to be done by the lower level and lower cost employees, we now have data entry at the highest level and highest cost. In addition, by using the physician's time to do data entry, the physician is no longer able to see and treat as many patients as they did before. Therefore, the physician's number-of-patients per physician-hour ratio goes down. Productivity is lost at the highest cost level and the data entry is now at the highest cost. This is not the best way to improve productivity or reduce costs. A host of other similar inefficiencies have resulted for the physicians, nurses, administrators, technicians and clerks as a result of the existing efforts to provide an IMS structure.
Medical treatment facilities are more interested in providing care for patients and less interested in the storage and retrieval of information, and they have a comfort level with the existing information systems. Electronic Information Management System companies appear to be more interested in the storage and retrieval of data than in how the users need to make use of that information. To move to an electronic IMS, many of a clinic's old manual sub-systems for accurately and efficiently collecting and recording patient information have to be redesigned and re-structured in order to accommodate the new electronic IMS structures. In most cases these redesigns have resulted in additional work at a higher cost level than before. In addition, they typically have not added any additional information to the patients' files. As health care workers are smart consumers of technology, they have resisted implementing technology that does not: (1) improve their speed and productivity, (2) make their jobs less complicated or complex, or (3) make their tasks more convenient. Consequently, many medical professionals resist solutions that require them to restructure how information flows within a medical center or clinic because current solutions do not meet the above criteria. Physicians particularly resist them as the new systems require them to enter the information within the medical center or clinic.
While medical centers and clinics may have some computerization of portions of data collection, storage, and reporting, the majority lack an automated integrated system. The area that has most consistently been computerized is the billing arena. However, even in billing, there is still heavy reliance on handwritten forms and paper databases, which produces inefficiencies and redundancies. As a result, after initial gains, costs have gone up and productivity has gone down. As such, the need for a new method and means for creating an electronic Information Management System that is cost effective, improves the productivity of the users, provides accurate information for medical and legal purposes and is user friendly has developed, particularly in the medical profession.
Due to health and economic pressures from the government, healthcare insurers, businesses and the public, there has also developed the need for health care providers to search for better ways to provide patient care at lower costs. This is forcing the health care facilities, and other businesses, to look across facilities and industries to find Best Practices. Finding Best Practices has turned out to be harder than anticipated for a variety of reasons. Some of those reasons include the lack of integrated systems, patient/physician confidentiality and, to some extent, the protection of patient information provided in the Health Insurance Portability and Accountability Act (HIPAA). A system which contains pertinent de-identified data could be utilized to provide benchmarks, though various media, that would allow a clinic or groups of clinics to compare their performance across a wide spectrum of similar businesses in order to improve business practices while maintaining patient information confidentiality.
In summary, there are clear, documented problems with the current ways that information is tracked. This is true for those clinics that are primarily manual as well as for those clinics that have attempted to migrate into a primary electronic format. Just as clear are all of the potential benefits from having access to electronic information. The current concepts for information management surround the idea of a paperless office. Despite all the promises and potential value such a situation would deliver, there remain many obstacles to achieving that goal. These obstacles include both the technical and cultural obstacles. Rather than insisting on a paperless IMS to achieve these goals as the only solution, there is another alternative. Rather than focusing on an electronic IMS as being the medical record, the IMS can and should focus on improving communications among health care workers and streamlining business practices and information flows.